Insurance Status, Clinical Severity, and Unmet Mental Health Treatment Needs for Youth with Complex Behavioral Health Care Needs

Background and Purpose: Youth with severe emotional disturbance (SED) exhibit a wide range of mental health disorders and symptoms, and the extent to which to which their functioning is impaired varies widely (Williams, Scott, & Aarons, 2017). Only 25% of any of these children and adolescents ever access any outpatient mental health treatment (Costello, Egger, & Angold, 2005). Even fewer obtain the intensive Home and Community-Based Services (HCBS) needed to keep youth with the most significant mental health needs safely in their home and communities (Spiker, 2017). Many families cite expense and lack of sufficient health coverage as barriers to service use (Owens et al., 2002); The only type of health coverage that routinely covers HCBS is Medicaid, leaving these services often financially inaccessible to families whose incomes are above the Medicaid means-test limits (Howell, 2004). Thus, youth with more significant mental health care needs may have better access to needed mental health treatment if they have public health coverage. This study sought to assess the relationship between a child’s type of health coverage (private, public, dual, or no coverage), the clinical severity of their condition, and the odds that they would have unmet mental health care needs and encounter cost barriers to treatment.

Methods: Utilizing data from the National Survey for Children with Special Health Care Needs from 2009/2010, analysis employed multi-level, random-intercept logistic regression. Models nested families within states, controlled for a variety of family and state level variables, and interacted insurance type with clinical severity to estimate relationships between types of insurance and three levels of clinical need.

Results: Results demonstrate that a child's coverage under public health insurance was not significantly predictive of reduced odds of having unmet mental health care needs when the youth has moderate clinical needs. However, the odds of having unmet mental health needs are estimated to be 12% lower for the most clinically severe youth if they have public insurance than for similar youth who have private insurance. The estimated odds of having unmet mental health needs are 25% greater for the most severe youth with private insurance (OR=1.25) than for similarly insured youth with moderate clinical needs. Further, for youth with moderate mental health needs, those with public insurance are estimated to have lower odds of experiencing delays or difficulty getting needed services due to cost barriers compared to similar youth with private insurance (OR=0.71). For youth with the highest clinical needs, the estimated odds of having unmet mental health care needs due to cost barriers are 46% lower for youth with public insurance versus private insurance.

Conclusion: This study highlights the role of clinical severity in unmet treatment needs and barriers to care, particularly for families with private insurance. Findings suggest that the most clinically severe youth with SED may have higher odds of having their mental health care treatment needs met and reduced odd of encountering cost barriers to care if they have public insurance.